Summary Of Exposure |
A) BACKGROUND: This management deals primarily with results of exposure to cactus or plant thorns or spines, rather than any toxic substances which might be included in the plant pulp. CACTACEAE: The Cactaceae are a large and diversified group of plants, many of which have thorns. Since the flesh and fruit of many of these species (especially Opuntia) are edible, spines are often encountered while other parts are being gathered for food. Cacti are distributed throughout the world and are used as houseplants. NON-CACTUS SPECIES: Plant thorn (eg, palm thorn) synovitis, granulomas, and other foreign body reactions from non-cactus species are also discussed.
B) EPIDEMIOLOGY: Encounters with cactus spines, needles, prickles and glochids (barbed hairs) are no longer rare. Household exposures are becoming more common. Significant injury is generally uncommon. ADVERSE EFFECTS: The clinical significance of cactus or other spines is roughly inversely proportional to the size of the spines.
C) WITH POISONING/EXPOSURE
1) ADVERSE EFFECTS: The clinical significance of cactus or other spines is roughly inversely proportional to the size of the spines.
2) MILD TO MODERATE INJURY: Mechanical damage may occur due to the spines and barbs of any of these species. Penetrating injuries due to spines commonly cause soft tissue swelling and inflammation. Itching and hypersensitivity can also develop following contact with spines. Occupational dermatitis is also common following glochid exposure. Granulomas have developed following cactus spine or plant thorn injuries. Bacterial and fungal infections have been reported, but are not common. Infection is more likely to occur if the spines or thorns are retained or incompletely removed.
3) SEVERE INJURY: Imbedded spines or plant thorns (eg, palm thorns are more likely to cause secondary complications) retained for long periods have resulted in foreign body granulomatous inflammation, synovitis, septic arthritis, osteomyelitis and periostitis.
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Heent |
3.4.3) EYES
A) KERATOCONJUNCTIVITIS: Two cases caused by Opuntia glochids have been reported (Whiting & Bristow, 1975).
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Genitourinary |
3.10.2) CLINICAL EFFECTS
A) TRAUMATIC PERFORATION OF BLADDER 1) WITH POISONING/EXPOSURE a) CASE REPORT: A 69-year-old man fell onto a thorny bush and developed a penetrating wound at the base of his scrotum that pierced the proximal penile urethra on the ventral wall that passed into the bladder. Initially, the only symptom noted was urine leakage from the scrotum during micturition only. A long thorn was found on radiologic exam. A communication between the urethral injury and the scrotal wound was confirmed via cystoscopic exam. The thorn was removed through a rigid cystoscope. A urinary catheter was placed for several days followed by a long term suprapubic catheter that allowed complete healing of the urethra. Complete healing was observed by 6 months with no urinary issues (Tan et al, 2013).
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Dermatologic |
3.14.2) CLINICAL EFFECTS
A) SKIN ULCER 1) WITH POISONING/EXPOSURE a) Mechanical damage may occur due to the spines and barbs of any of these species. The penetration of a cactus spine may create a mass resembling a sarcoma or a pseudotuberculous lesion of the bone. Soft tissue swelling and inflammation are common (Karpman et al, 1980). Cactus spines may break off in the skin and be the cause of secondary infections and cause ulceration (Mitchell & Rook, 1979; Sutton, 1918).
B) DERMATITIS 1) WITH POISONING/EXPOSURE a) Occupational dermatitis (Sabra dermatitis) has been seen in workers asked to pick the fruits of Opuntia species, especially O. ficus-indica (Shannon & Sagher, 1965). The disease is called Sabra's disease by those picking the fruits for a living (Shannon & Sagher, 1965). There is usually an itchy papular dermatitis that is most often found in the webs of the fingers but may appear anywhere, including the face, cheeks, hard palate, tongue, and gastric mucosa. Oral symptoms are more commonly found in patients who try to suck out the glochids. The skin of workers has developed the appearance of scabies or the appearance of fiberglass dermatitis (McGovern & Barkley, 2001; Mitchell & Rook, 1979; Shannon & Sagher, 1965).
b) Extremely tender, erythematous, non-fluctuant papules were described in a series of 25 cases of spine injury (Karpman et al, 1980).
c) Glochids (fine hairs or spines) of O. ficus-indica may become airborne and produce dermatitis in areas some distance from the plant, or be drawn into a building via air ducts (Mitchell & Rook, 1979).
d) Attempting to suck out a spine that is causing mechanical damage or irritation may result in glochids being imbedded in the tongue, hard palate or other mouth parts (Mitchell & Rook, 1979).
e) The glochids of many Opuntia species are irritating and may cause intense irritation. These fine hairs may be transferred via the clothing of exposed individuals (Mitchell & Rook, 1979).
C) GRANULOMA 1) WITH POISONING/EXPOSURE a) Acute dermatitis followed by granuloma formation for 4 months duration has been reported with exposure to the bristles of O. macrodasys (Bunny's ears cactus) (Snyder & Schwartz, 1983), and other organic plant material such as thorns, twigs, wood slivers (Yousefzadeh & Jackson, 1978). b) McManigal & Henderson (1986) reported granulomatous lesions infected with Mycobacterium marinum caused by cactus spines (McManigal & Henderson, 1986). c) Granulomas have been reported with a number of Opuntia cactus exposures (Spoerke & Spoerke, 1991; Ormerod et al, 1984; Schreiber et al, 1971; Winer & Zeilenga, 1955) as well as plant thorns (Butler, 1995). 1) The onset may be days to weeks after exposure and may be mistaken for infection, hypersensitivity, or a toxic reaction (Spoerke & Spoerke, 1991). 2) Occasionally granulomatous areas may need to be opened to remove foreign material. In one study, granulomas were unroofed using a dissecting microscope. Granulomatous papules were found that contained spines still in the skin. After removal, the areas were soaked in an antibacterial soap. These 2-week-old, swollen, and painful papules resolved quickly (most less than a week) after removal of the foreign body. A topical steroid was of little benefit prior to removal of the spines. a) The exact mechanism of granuloma formation is unknown, but may involve some allergic mechanism. One study demonstrated a positive skin test reaction in 4 of 6 patients who developed granulomas (Doctoroff et al, 2000).
d) Hyperpigmentation frequently develops at the sites where the spines have been imbedded. It may resolve on its own over time (Spoerke & Spoerke, 1991; Snyder & Schwartz, 1983). D) POST-TRAUMATIC WOUND INFECTION 1) WITH POISONING/EXPOSURE a) Infection is not common. Culture from mild lesions were negative for bacterial growth in 21 patients (Karpman et al, 1980).
b) Periosititis and bacterial arthritis have been reported from Pantoea agglomerans (formerly known as Enterobacter agglomerans), a coliform facultative anaerobic Gram-negative rod that can be found in soil and vegetation (Duerinckx, 2008; Rosenfeld et al, 1978; Barton & Saied, 1978).
c) S. aureus, beta-hemolytic streptococci, Enterobacter, and Bacillis subtilis have also been isolated (Karpman et al, 1980; Kleiman et al, 1977; Jackson, 1974; Maylahn, 1952).
E) MYCOSIS 1) WITH POISONING/EXPOSURE a) FUNGAL ORGANISMS including Alternaria, Candida, and Aspergillus were cultured from the SPINES and glochid collected from prickly pear, and the spines were collected from barrel, hedgehog, and cholla cacti. No fungi were cultured from the wounds of patients in this series (Karpman et al, 1980). An Alternaria tenosynovitis was reported after a thorn penetration in a 6-year-old boy. The digital flexor tendon sheath was penetrated. Treatment consisted of tenosynovectomy and prolonged itraconazole treatment (Brady & Sommerkamp, 2001) (Turkal & Baumgardner (1995) report Candida parapsilosis from a rose thorn.
b) CASE REPORT: A 6-year-old boy fell onto a cholla cactus (Opuntia species) with several spines retained in his arm and flank area (the spines were removed by a parent). One week after the initial injury the patient developed severe abdominal pain; surgical evaluation found a thrombosed renal artery with an ischemic left kidney. A nephrectomy was performed. Persistent abdominal pain and poor wound healing were observed and Apophysomyces elegans was cultured from the wound site. Despite a complicated hospital course with ongoing infection and multiple wound debridements, the child had a full recovery following liposomal Amphotericin B infusions (Burrell et al, 1998).
F) SKIN IRRITATION 1) WITH POISONING/EXPOSURE a) Some cacti may contain irritants or allergens that cause reactions.
b) Various Euphorbia species have spines and resemble cacti. Many of these species have an irritant effect, and sometimes allergic material in their sap may produce large blisters. If blistering and a white latex is involved, consider that there may be Euphorbia dermatitis as well as mechanical damage (McGovern & Barkley, 2001). Please refer to the PLANTS-EUPHORBIACEAE management for further information.
G) ITCHING OF SKIN 1) WITH POISONING/EXPOSURE a) Application of Cactus grandiflora to the skin has caused pruritus, pustules, and excoriations (Mitchell & Rook, 1979).
b) The inflammatory response to cactus spines may be caused by allergy to the fungus Alternaria, which was cultured in 17/25 spines collected from various cactus species (Karpman et al, 1980).
c) Intradermal skin testing using cholla and prickly pear antigen induced an allergic reaction in 7/9 subjects, however, scratch testing in the same subjects caused a reaction in only two subjects (Schreiber et al, 1977). Patch testing using extracts from the seeds and fruit from prickly pear in 12 subjects failed to elicit an antigen-antibody response (Shannon & Sagher, 1965).
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Musculoskeletal |
3.15.2) CLINICAL EFFECTS
A) SYNOVITIS 1) WITH POISONING/EXPOSURE a) Synovitis may be due to imbedded thorns (Miller et al, 2000; Kahn, 1978).
b) PLANT THORN SYNOVITIS is a term used to describe the spectrum of monoarticular arthritis, joint effusions, para-articular erosions, periosteal reactions, and soft tissue inflammation with periostitis when thorns become embedded. The type of thorn is of little significance (Miller et al, 2000; Sperber et al, 1990).
c) The affected joint may be a finger, wrist, elbow, knee, or ankle (Stevens et al, 2000; Ramanathan & Luiz, 1990; Doig & Cole, 1990). Cases may simulate juvenile rheumatoid arthritis with monoarticular involvement and septic arthritis (Taskiran & Toros, 2002).
d) ROSE THORN INJURY: CASE REPORT: A 57-year-old healthy man was pricked by a rose thorn in the knee and developed increased swelling and pain in the knee about 2 weeks after the event. He had a large intraarticular effusion. A plain film x-ray was normal. Aspiration of the knee, resulted in 60 mL of purulent fluid which later grew Pantoea agglomerans. Urgent arthroscopy of the knee was performed which showed mild synovitis and no evidence of an intraarticular foreign body. He gradually recovered with antibiotic therapy (temocillin) (Duerinckx, 2008).
e) ZANTHOXYLUM AILANTHOIDES THORN INJURY: CASE REPORT: A 58-year-old woman developed plant thorn synovitis after a bristle of Zanthoxylum ailanthoides (an aromatic plant from East Asia) penetrated her hand. Initially, she removed the thorn herself. About 3 weeks later she developed painful swelling of her third metacarpo-phalangeal joint. High-resolution ultrasonography detected a 2.7 mm foreign body and synovial proliferation at the joint. The thorn and surrounding granulomatous synovial tissue was removed surgically, and synovitis resolved completely (Tung et al, 2007).
B) BACTERIAL ARTHRITIS 1) WITH POISONING/EXPOSURE a) SUMMARY: Although not reported frequently, a thorn injury to a joint can mimic septic arthritis. A careful history of a penetrating injury to the knee or a joint by plant material should be considered when evaluating a patient with sudden pain and swelling of a joint (Rave et al, 2012; Clarke & McCaffrey, 2007; Kratz et al, 2003).
b) PALM THORN INJURY: A 14-year-old boy developed septic arthritis after a palm thorn penetrated his knee. He was initially treated with oral amoxicillin-clavulanate for 10 days. Six weeks later, significant swelling and pain in the knee with a limited range of motion (both active and passive) developed. Aspiration yielded 80 mL of purulent fluid that was positive for leukocytes only; final culture results were positive for Pantoea agglomerans and amoxicillin-clavulanate (3 g/day) IV was started. An ultrasound was positive for fluid accumulation in the suprapatellar bursa and an 8 mm long foreign body. An initial arthrotomy revealed no foreign body. However, after minimal clinical improvement, a second arthrotomy was performed and fragments of a foreign body and pus were found lateral to the initial location. A postoperative ultrasound was negative. He recovered completely (Kratz et al, 2003).
c) PALM THORN INJURY: A 4-year-old boy developed septic arthritis of the knee after suspected Bougainvillea or palm thorn injury. Initially, he did well with oral cephalexin but swelling and pain returned 2 weeks later. An ultrasound detected a 5 mm thorn. Arthroscopy was performed and the thorn was removed, and there was evidence of mild synovitis. The initial culture was sent for further evaluation and Pantoea agglomerans was identified. Cefuroxime IV was started for 1 week followed by oral amoxicillin-clavulanate for 3 weeks. The child had been exposed to palms during a religious ceremony. Recovery was uneventful (Rave et al, 2012).
C) OSTEOMYELITIS 1) WITH POISONING/EXPOSURE a) CASE REPORTS: Osteomyelitis secondary to a thorn prick in the foot was reported in 4 individuals that had been walking barefoot. In each case, the injury had occurred months before presentation. Surgical exploration was needed to remove the thorn and granulation tissue when present. Of the 2 patients that had positive cultures; one grew Pseudomonas aeruginosa and one grew Staphylococcus aureus. Each recovered with surgical removal (Vidyadhara & Rao, 2006).
b) Osteoblastic or osteolytic changes have been reported to be due to imbedded thorns (Lampe & McCann, 1985).
c) Bone changes resembling tumoral lesions or pseudotumors have been reported from palm tree thorns. Three cases of young boys presented with pain, local inflammation, and radiographic evidence of bone changes. The causative agent and correct diagnosis was not made until the thorns were removed surgically. Post operative care was unremarkable (Vega et al, 2001).
D) PERIOSTITIS 1) WITH POISONING/EXPOSURE a) PALM THORN INJURY: A young adult with a history of aphasia and deafness developed a sudden onset of pain and swelling without discharge in his foot and was diagnosed palm thorn-induced periostitis. Two years previously, he reported that something had pricked his foot. He had swelling and tenderness at the base of the fourth metatarsal. Laboratory analysis was normal. An x-ray showed evidence of an osteolytic lesion, and a CT showed an oblique dorso-plantar channel with thickening of the soft tissue on the dorsal side. During surgical exploration, a 2.5 cm palm thorn was removed along with a granuloma; no bone grafting was needed. The patient was placed on prophylactic antibiotic therapy (ie, amoxicillin and clavulanic acid) for several months due to the patient walking barefoot most of the time. At 3 months follow-up, the patient was asymptomatic (Madhar et al, 2013).
b) PALM THORN INJURY: A 10-year-old boy had a history of pain and swelling of the dorsum of the foot for 2 months with a prior history of playing on a date palm plantation 3 months earlier. The child reported no specific injury. A routine x-ray revealed periosteal inflammation over the fourth metatarsal. An ultrasound showed a granuloma between the third and fourth metatarsal, and a CT scan detected a foreign body in the fourth metatarsal. During surgery, a 17 mm date thorn and granulation tissue were removed. Culture of the excised tissue remained negative (Suresh, 2011).
E) CONTRACTURE OF PALMAR FASCIA 1) WITH POISONING/EXPOSURE a) Dupytrens contracture developed in a patient with a retained spine. The symptoms resolved upon removal of the spine (Karpman et al, 1980).
F) INFLAMMATION 1) WITH POISONING/EXPOSURE a) INFLAMMATION and pain developed in a 3-year-old with a 40 cm spine retained in the cartilaginous epiphysis of the proximal tibia (Stevens et al, 1995).
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Endocrine |
3.16.2) CLINICAL EFFECTS
A) HYPOGLYCEMIA 1) WITH POISONING/EXPOSURE a) Decreased serum glucose levels and serum insulin levels have been observed in non-insulin dependent diabetics after ingestion of stems of Opuntia sterptacantha (Frati-Munari et al, 1988). It is unknown if this effect was due to the pulp of the plant, or the effect of swallowing the thorns.
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